New Patient Paperwork 2023

Patient Acquaintance Form
Name:
Address:
City:
State:
Zip:
Home Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Cell:

Area CodePhone Number
E mail:
example@example.com
Birthdate:

MonthDayYear
Date
Marital Status

SingleMarried
Social Security #
Sex:

MaleFemale
Insurance Coverage:

YesNo
Name of Insured:
Date of Birth of Insured:

MonthDayYear
Date
Social Security of Insured:
Employer Name:
Referred By:
Medical History
Are you allergic to any drugs or medications? (Yes/No) If yes, please list

YesNo
List Drugs or Medications
Do you have artificial joints such as knee or hip replacements? If yes, please list with date:

YesNo
List Surgey Type
Surgey Date

MonthDayYear
Date
High blood pressure? (Yes/No) If yes, please list medication:

YesNo
List Medications
A heart ailment, including mitral valve prolapse or heart murmur? (Yes/No)

YesNo
Do you have a history of heart surgery? (Yes/No) If yes, please list:

YesNo
History of Heart Surgey:
Do you have Diabetes? Do you have Rheumatic fever? Do you have HIV or AIDS? If yes, please list medication:

DiabetesRheumatic feverHIV or AIDS
List Medication for Diabetes, Rheumatic fever, HIV or AIDS:
Do you have Hepatitis? (Yes/No) If yes, please list type:
Have you ever had any radiation treatment? Do you have epilepsy, convulsions, or seizures? Do you have any pain in or near your ears? Check all that apply.

Radiation Treatment?Epilepsy , Convulsions or Seizures?Pain in or Near your Ears?
Are you pregnant? (Yes/No) If yes, how many months?
Are there any other conditions we should be aware of?
Are you presently taking drugs or medications not listed above for any other medical condition? If so, please list, if not enter "None"*
List Medications
Dental History
Do you have or have you ever had any of the following: Click all that apply

Bleeding, sore gumsClenching/grinding?Clicking/popping jaw?
Do you have or have you ever had any of the following: Click all that apply

Sensitive teeth (hot or cold)?Teeth sensitive to sweets?Orthodontic Treatment for BracesDeep cleanings-Scaling/root planning
Dental Hygiene *
Is there anything about your teeth you would like to change?
Do you want whiter teeth?
In case of emergency,notify:
Phone Number

Area CodePhone Number
Unless prior arrangements have been made, payment is expected at time of service. In order to provide the best possible service, please notify us at least 24 hours in advance if you are not able to keep an appointment. Broken appointments will be subjected to a charge.

I certify that the above information is true and accurate to the best of my knowledge. I accept full financial responsibility for my account, including any fees which are assessed to my account to collect any outstanding balance.
Signature*

Clear
Date

MonthDayYear
Date
Acknowledgement of receipt of notice of privacy practices

*You may refuse to sign this acknowledgement*
I have received a copy of this office’s Notice of Privacy Practices.

YesNo
Please print name
Signature

Clear
Date

MonthDayYear
Date
Authorization to release specific protected health information

*Per your request we are allowed to fax dental excuses to your school or business*
Please print name
Signature

Clear
Date

MonthDayYear
Date
Electronic Consent
We now have the ability to email and/or text you, reminding you of your appointments.
If you would like to receive this feature in the future, please read the consent below and sign. Consent to Email and/or Text Message for Appointment Reminders, Statements and Other Healthcare Communications:

Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information.
I consent to receiving appointment reminders and other healthcare communications/information via email or text from Hightower Dental Concepts.

YesNo
I consent to emails, to receive communications as stated above. The email that I authorize to receive email messages for appointment reminders and general health reminders/feedback/information. Please enter the email you would like to use.
I consent to receive text messages from the practice at my cell phone and any number forwarded or transferred to that number.The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health. Please enter the phone number you would like to use.
I understand that this request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing.
Signature

Clear
Date

MonthDayYear
Date
For office use only

We attempted to obtain acknowledgement of receipt of our notice of privacy practices, but acknowledgement can not be obtained because
Individual refused to signcommunications barriers prohibited obtaining acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (please specify)
Should be Empty:

Patient Acquaintance Form

Medical History

Dental History

Electronic Consent